People with a first or recurrent psychotic episode tend to present late for medical attention, and many do not present at all. Presentation is often initiated by others, not by patients themselves. Psychosis can also become apparent during a manic presentation, when patients act on their delusions in a public forum, or when they have the complications of substance misuse. Patients who experience intolerable symptoms (distressing delusions or voices; box 1) often seek medical help. In emergency settings, family members' concerns contrast with the patient's apparent indifference. The highest risk of suicide in people with schizophrenia occurs during the first five years of illness (“the critical period”), and interventions are most fruitful during this time. Importantly, patients experiencing their first episode should quickly be given competent assessments and access to appropriate services.

Summary points

Acute psychosis is a common psychiatric emergency that may present to health services other than mental health practitioners

Comorbidities are common and increase with age—monitoring for hidden physical and other mental disorders is essential

Patients with a first episode (even those with substance misuse) are best treated by specialist multidisciplinary early intervention teams that deliver psychosocial interventions as essential adjuncts to drugs

Treatment achieves complete remission, without relapse, in 25% of patients

In general, a low dose, well tolerated atypical antipsychotic drug will increase medium term adherence and reduce future relapses

Sources and selection criteria

I searched HighWire and PubMed from 2002 to October 2006 for randomised controlled trials and systematic reviews of treatments for psychosis and schizophrenia. I reviewed the Cochrane Database of Systematic Reviews using both terms, across the age spans. Influential articles, key texts, and published treatment guidelines are also included.

Box 1 Positive psychotic symptoms

Clear symptoms (one or more needed for a diagnosis of schizophrenia)

Paranoid delusion: Any delusion that refers back to the self—in practice, most are persecutory delusions. Grandiose delusions (such as special powers or missions) occur in schizophrenia and bipolar …